1 evaluation of home telehealth following hospitalization for heart failure: a randomized trial...

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Evaluation of Home Telehealth Following

Hospitalization for Heart Failure: A Randomized Trial

Funded by VA HSR&D NRI 99-345-1 & HSR&D Career Development Award 99-311-1

Bonnie Wakefield, PhD, RNHarry S Truman Memorial Veterans Hospital

Sinclair School of Nursing & School of Medicine, University of Missouri

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Objectives

• Provide an overview of telehealth care • Compare two forms of telehealth vs. usual

care for veterans with heart failure• Compare nurse-patient communication

patterns in two modes of telehealth care

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Telehealth Background

• Care moving from hospital clinic home• Increasing rates of chronic illness• Unique challenges for rural health care

– Elderly– Remote from health care centers– Lack formal support services– Traditional home care limited by distance

• Advances in computing and telecommunications technologies

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Telemedicine

• The use of audio, video, and other telecommunications and electronic information processing technologies to provide health services or assist health care personnel at distant sites (IOM, 1996)

• Other terms: telehealth, remote monitoring, smart devices

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Candidates for Telehealth Home Care

• Non compliant with treatment plan, medications, diet, or self-monitoring of key indicators

• High risk for frequent changes in condition• Newly diagnosed• Lack of caregiver support• Frequent use of health care services• Isolated or distant from provider (rural &

urban, transportation issues)

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VA Care Coordination Home Telehealth (CCHT) Program

• VA 2nd largest provider of telehealth services (DoD first) – physician visits, teleretinal imaging, store and

forward radiology

• VA Office of Care Coordination is implementing home telehealth & remote monitoring nation wide– 30,000+ veterans enrolled

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Evidence Base for Telehealth

Review (Hersh et al. 2006)

• 44 studies

• Studies limited by small samples &/or lack of control group (what is usual care?)

• Conclusions– may enhance communication with health providers &

provide closer monitoring

– required additional resources & dedicated staff, i.e., not integrated into routine care

– gaps in the evidence base in telehealth

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Heart Failure Study TeamInvestigators:• PI: Bonnie Wakefield, PhD, RN• Marcia Ward, PhD• Michael Kienzle, MD• Trudy Burns, PhD• Gary Rosenthal, MD

Study staff:

• John Holman, MA, Project Director• Annette Ray, RN• Melody Sherubel, RN

Iowa City VA Medical CenterVA HSR&D Center for Implementation of Innovative Strategies in Practice

(CRIISP)University of Iowa College of Public Health & College of Medicine

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PURPOSE

• To compare the effectiveness of telehealth to usual care in recently discharged outpatients with heart failure (HF):– readmission rates– urgent care visits– mortality

• Secondary outcomes– quality of life– self-efficacy– medication adherence

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BACKGROUND• Heart failure is one of the most common

reasons for hospitalization in older patients• Frequent admissions common• Telehealth technologies may facilitate detection

of early signs of decompensation prevent hospitalization

• Few empirical studies have compared telehealth to traditional outpatient care

• One previous study compared the effectiveness of alternative telehealth applications (Jerant et al. 2001)

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DESIGN• Randomized controlled clinical trial• Compared usual care to a nurse managed

intervention delivered by either telephone or videophone

• Veterans following discharge from the hospital• Treatment group subjects (telephone or

videophone) received the intervention for 90 days following discharge from the hospital

• Subjects in the usual care group received traditional outpatient care

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Inclusion Criteria

• Hospital admission with HF exacerbation

• Telephone line in home

• No hearing, visual, or communication impairments

• Cognitively intact

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INTERVENTION

• Provided an electronic blood pressure monitor & scale instructed to measure daily vital signs and weights; tape measure for ankles

• Mutually agreed upon scheduled “appointment” times • Symptom Review Checklist to assist patients• Nurses reinforced positive behaviors, teaching, &

recommendations as needed• If the patient reports deterioration or if the nurse notes

problems over the phone, e.g., worsening shortness of breath, she provided guidance and/or consulted with the appropriate provider (e.g., physician, dietitian, pharmacist).

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Video Phone

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Video Phone

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SAMPLE• Enrolled n=148 over 3 years

– 19 deaths (12.2% 6-month mortality)– 20 lost to follow up (13 drop-outs; 4 quit

participating; 3 moved)– 109 with complete data

• Three groups – 33 (52) videophone (63% completed)

• n=19 (9 died; 6 drop outs; 2 stopped participating; 2 relocated)

– 34 (47) telephone (73% completed)• n=13 (5 died; 6 drop outs; 1 stopped participating; 1

relocated)

– 42 (49) usual care (85% completed)• n=7 (5 died; 1 drop out; 1 stopped participating)

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SAMPLE

• 99% male • 94% Caucasian• Average age at enrollment 69.3 years• 33% less than 12 years education• No significant differences across three groups

at enrollment for severity of illness measures:

– New York Heart Association (NYHA) classification– index admission length of stay– left ventricle ejection fraction (LVEF)*– prior revascularization– length of time with HF diagnosis*

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Intervention Dose

Telephone

All subjects (N=47)

Telephone

completers (N=34)

Videophone

All subjects

(N=52)

Videophone

completers

(N=33)

Mean # intervention visits

11.4 (3.9) 13.2 (1.4) 10.5 (5.4) 13.4 (0.9)

Mean length of visits (minutes)

33.5 (11.7) 36.5 (12.4)

19Intervention

Usual CareSAS Proc LifetestLog-Rank p=.02

Survival Analysis: Time to First Readmission (365 days)

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Cox Proportional Hazards Models: Intervention vs Control Time to First Readmission and Death

First AdmissionModel Fit p=0.14

DeathModel Fit p=0.08

CovariateHazard Ratio

(95% CI) p=Hazard Ratio

(95% CI) p=

Intervention 0.54 (0.33-0.90) 0.02 1.04 (0.49-2.24) 0.91

LVEF 1.01 (0.99-1.02) 0.37 0.98 (0.96-0.99) 0.04

NYHA Classification

1.38 (0.85-2.24) 0.19 1.15 (0.61-2.17) 0.67

Age at Admission

0.99 (0.97-1.03) 0.81 1.00 (0.97-1.04) 0.77

MLHF* 1.00 (0.99-1.01) 0.77 1.02 (0.99-1.03) 0.07

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Secondary Outcomes

• Medication changes at 90 days (p=0.04)– 29% control– 48% telephone– 59% videophone

• Medication adherence – no difference

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Secondary Outcomes

• Quality of life – improved for all groups; no significant differences

• Self-efficacy – no differences

• Satisfaction – no differences

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SUMMARY

• Intervention was effective in reducing time to first readmission during the active intervention period

• Effect was not sustained at 6 months• No differences in Urgent Care visits or

mortality• Usual care group had access to Primary

Care nurse case manager & Cardiology nurse case managers

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Summary• Telehealth-facilitated care has the potential to enable

earlier detection of key clinical symptoms, triggering early intervention and thus reducing the need for hospitalization

• The VA Office of Care Coordination is implementing home telehealth nation wide

• Currently published studies are mixed re: efficacy of care management in HF

• Further work is needed to determine which technologies work for specific patient populations, and to determine the effective intervention dose

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INTERVENTION ANALYSIS

• Qualitative analyses– Roter Interaction Analysis System– Instrumental/task oriented

• gathering data, information giving

– Affective/socioemotional• building a relationship, activating and partnership

building

– 36 sub-categories

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INTERVENTION ANALYSIS

• Compared 14 video sessions and 14 telephone sessions over 90 day intervention period

• Nurses were more likely to use open-ended questions, back-channel responses, friendly jokes, and checks for understanding on the telephone compared to videophone

• Patients were more likely to give lifestyle information and approval comments on the telephone, and used more closed-ended questions on the videophone

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FUTURE RESEARCH

Targeting - matching appropriate technology to the patient (disease severity, literacy, age)

• Intervention dose and timing (frequency, duration, post-discharge transitions)

• Comparison of low-cost low-tech & higher cost more complex telehealth interventions (telephone vs web based interventions)

• Caregivers